Before and After School Care

Before and After School Care BLAIR FAMILY YMCA 2016-2017 School Year Registration Forms To put Christian principles into practice through programs that build a health spirit, mind and body for all. -YMCA Mission

2016-2017 Before & After School Registration Forms In the YMCA Before and After School Care, kids engage in physical, learning and imaginative activities that encourage them to explore who they are and what they can achieve. They will get assistance with their homework from YMCA staff members, have a chance to socialize with each other and form long-lasting friendships that enhance their development, growth and self-confidence. Transportation to and from school is provided along with an afternoon snack. How to Register: The following information must be completed and submitted prior to your child s first day: A completed registration form A copy of your child s immunization records A completed Rapid Tuition form $25.00 registration fee (New Children only) Ages: 5-12 Years/K-6 Grades Time: 6:00-7:750 a.m. and 3:45-6:00 p.m. Rates: Before School Member: $6.00 a day for the first child each additional child is $5.00 a day Before school Non-member: $7.50 a day for the first child each additional child is $6.50 a day After School Member: $8.00 a day for the first child each additional child is $7.00 a day SCHOOL S OUT FUN CLUB When school is out, the Y is in! We provided a full day of fun while the kids are out of school. Kids will enjoy themed days with activities, learning and fun. They will do arts and crafts, games in the gym, swim and if weather permits, play outside. Morning and afternoon snack provided, but please bring a sack lunch. Ages: 5-12 years/k-6 Grades Time: 6:00 a.m.-6:00 p.m. Fee: $30 member/$40 non-member *Must Register one week prior to the day the kids are out Dates: September 23rd, 26th October 24th November 23rd December 27th, 28th, 29th, 30th January 3rd, 4th February 17th, 20th March 8th, 9th, 10th April 17th May 24th, 25th, 26th *There is a $25.00 Registration Fee for New Children

All information must be filled in completely in order to process your registration. CHILD INFORMATION First Name MI Last Name Date of Birth Age Grade for 2016-17 School Gender M/F Address Home Phone City State Zip PARENT/GUARDIAN INFORMATION Mother/Legal Guardian Name: Address: If same as child s check here City State Zip Cell Phone Employed By Address Work Phone Home Phone Email Father/Legal Guardian Name: Address: if same as child s check here City State Zip Cell Phone Employed By Address Work Phone Home Phone Email In Case of EMERGENCY, we should contact the following person( s) if parents cannot be reached: (Please list names in order you would like them to be called. List at least 2) A. Phone Relation authorized pick up B. Phone Relation authorized pick up C. Phone Relation authorized pick up D. Phone Relation authorized pick up AUTHORIZED person( s) to take child from site: (You must list anyone allowed to pick up your child and they must be over the age of 18) A. Relation to child Age B. Relation to child Age C. Relation to child Age Is there anyone UNAUTHORZIED to pick up or visit your child? (If possible please provide a picture)

Child: First Name: MI: Last Name: YMCA Member Non Member Email: School: Grade: Before school After School Days Attending Monday Tuesday Wednesday Thursday Friday HEALTH INFORMATION ANY KNOWN ALLERGIES? Severity: Mild Moderate Severe ANY KNOWN SPECIAL NEEDS OR HEALTH ISSUES? ANY ACTIVITIES YOUR CHILD MAY NOT ENGAGE IN? Medication, if any: Possible side effects: Will this medication be taken while he/she is in Before and After care? Yes No Any special devices used (glasses, hearing aids, crutches, etc.)? Does your child have any fears that we should be aware of (insects, water, heights, animals, etc.)? Has any event occurred that could cause emotional concern that we should be aware of? (Death in the family, Divorce, etc.?) Any known intolerance to food, insect bites/stings, or other factors that result in medical reaction? Please provide us with clear instructions in the event of an exposure to the factor. AUTHORIZATION FOR EMERGENCY MEDICAL CARE I (we) expect to be notified at once in case of an accident or illness to my/our child; I/we will make arrangements for medical care of my/our child with the physician or hospital of my/our choice; if I/we cannot be reached to make the necessary arrangements, I/ we hereby authorize the YMCA to contact: Dr. at ADDRESS PHONE Or the nearest hospital for emergency medical treatment of CHILD S NAME Furthermore, I/we certify that my child is, to my/our knowledge, in good health and free of disabilities that would endanger him/ her or other children in the YMCA programs. MEDICATION PERMISSION AND COMPETENCY I have determined that the YMCA staff is competent to give or apply medication to my child. I understand that the YMCA has the responsibility to assess the ability of staff to give or apply medication safely and may give or apply medications to my child. Parent s Signature Date

PARENT/GUARDIAN PERMISSIONS My child has permission to swim during the school year My child has permission to swim in the deep end- The deep end is any water above the height of your child s head. Swimming ability Non-Swimmer Fair Good I give to the YMCA, its nominees, agents and assigns, unlimited permission to use and publish testimonials, photos, videos, etc. for purposes of advertising and/or education. Parent s Signature Date TRANSPORTATION RELEASE Transportation may be provided by a private provider, a YMCA owned and operated vehicle and/or public transportation systems in the area. I (we) the undersigned understand and authorize the YMCA to transport my child to and from school while enrolled in the YMCA Before and After school program. The signing of this permission slip releases and indemnifies the YMCA and its agents and/or employees from all liabilities, damages and any claims made by the child or on behalf of the child, including medical expenses incurred, should serious injury, loss of property, damages or death occur as a result of his/her participation in the transportation program. We fully understand the nature of the transportation services and the risk of serious injury, loss of property, damages or death associated with these services. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as release ) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participating in any program affiliated with the YMCA, without respect to location. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releases or otherwise. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE due to negligence of releases or otherwise while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participation in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. I HAVE READ THE RELEASE (Parent and/or Guardian) Printed name of participant Parent s signature Date

2016 Before and After School Care Payments PAYMENT INFORMATION CONVENIENT AUTOMATIC PAYMENT OPTIONS: We are now offering an automatic payment option. Payments will be drafted on the Monday after attendance. Please check credit card or bank draft option and fill out the information below. EFT/BANK DRAFT Bank Name: Checking Account Number: Routing Number: DEBIT/CREDIT CARD DRAFT Card Type (Check one): VISA MASTERCARD DISCOVER Credit Card Number: Name on Card: Exp. Date: CVC Number: I hereby request and authorize the Blair Family YMCA to charge my account. The amount depends on the number of days my child attends Before and After care. Parent Signature (required): Parent Email (required): Parent Phone Number required): YMCA Staff Initial: Date: